Mentalization Based Therapy (MBT) by John M. Grohol, Psy.D.

Mentalization
based therapy (MBT) is a
specific type of
psychodynamically-oriented
psychotherapy designed to help
people with borderline
personality disorder (BPD). Its
focus is helping people to
differentiate and separate out
their own thoughts and feelings
from those around them.

People with
borderline personality disorder
tend to have unstable and
intense relationships, and may
unconsciously exploit and
manipulate others. They may find
it difficult or impossible to
recognize the effects their
behavior has on other people, to
put themselves in other people’s
shoes and to empathize with
others.

Mentalization
is the capacity to understand
both behavior and feelings and
how they’re associated with
specific mental states, not just
in ourselves, but in others as
well.
“ Mentalization” is the
ability to perceive the mind of
others as distinct from one's
own and hence to reconsider and
reassess one's own perceptions
of reality. It is theorized that
people with borderline
personality disorder (BPD) have
a decreased capacity for mentalization. Mentalization is
a component in most traditional
types of psychotherapy, but it
is not usually the primary focus
of such therapy approaches.

In
mentalization-based therapy (MBT),
the concept of mentalization is
emphasized, reinforced and
practiced within a safe and
supportive psychotherapy
setting. Because the approach is
psychodynamic, therapy tends to
be less directive than
cognitive-behavioral approaches,
such as dialectical behavior
therapy (DBT), another common
treatment approach for
borderline personality disorder.

In someone
with BPD, the difference between
the person’s inner experience
and the perspective given by the
therapist (or others), as well
as the person’s attachment to
the therapist (or others), often
leads to feelings of
bewilderment and instability.

Unsurprisingly, this leads to
more, rather than less, problems
in the person’s life. It has
been proposed that people with
BPD have hyperactive attachment
systems as a result of their
history or biological
predisposition, which may
account for their reduced
capacity to mentalize. They
would be particularly vulnerable
to side-effects of
psychotherapeutic treatments
that activate the attachment
system.

Yet without
activation of the attachment
system, people with BPD will
never develop a capacity to
function in a healthy manner in
the context of interpersonal
relationships.

Mentalization,
like socialization or public
speaking, is a skill which can
be readily learned. People who
undergo MBT will find that their
therapy experience focuses on
learning and practicing this
skill in the context not only of
their social relationships with
others, but also directly with
their therapist.

Mentalization-Based Therapy
Shows Promise With BPD by Mark Moran

All of the
structured psychotherapies—including
dialectical-based therapy, transference-based
therapy, and schema-focused therapy—are proving
superior to treatment as usual in randomized control
trials.

Five
years after discharge, patients with borderline
personality disorder (BPD) treated with
mentalization-based therapy during partial
hospitalization followed by maintenance mentalizing
group therapy showed clinical and statistical
improvement on a range of measures compared with
patients receiving treatment as usual.

Those
measures included suicidality, diagnostic status,
service use, use of medication, global function, and
vocational status, according to a report in the
March 17 edition of AJP in Advance.

“More
striking than how well the mentalization-based
treatment group did was how badly the
treatment-as-usual group” fared despite extensive
treatment, wrote study authors Anthony Bateman,
M.D., and Peter Fonagy, Ph.D.“ They look little
better on many indicators than they did at 36 months
after recruitment to the study. A few patients in
the mentalization-based treatment group had made at
least one suicide attempt during the postdischarge
period, but this was almost 10 times more common in
the treatment-as-usual group.

“The
treatment-as-usual group also experienced more
emergency room visits and greater use of
polypharmacy,” Bateman and Fonagy added.

The
study, “8-Year Follow-Up of Patients Treated for
Borderline Personality Disorder: Mentalization-Based
Treatment Versus Treatment as Usual,” is the latest
analysis of a randomized trial first reported in
AJP in October 1999 and titled “Effectiveness
of Partial Hospitalization in the Treatment of
Borderline Personality Disorder: A Randomized
Controlled Trial.”

Joel
Paris, M.D., an expert on BPD, explained that
mentalization therapy, developed by Bateman and
Fonagy in the 1990s, is based on attachment theory
and on observations that BPD patients have a failure
of“ mentalization”—the ability to observe their own
emotions and those of other people and to appreciate
how their behavior may affect others.

“Mentalization-based therapy can be considered as an
amalgam of psychodynamic and cognitive methods,” he
told Psychiatric News.

For
instance, a case report included in the study
describes a 24-year-old woman who was referred from
forensic services after her arrest for setting fire
to her university dormitory.

She
had a history of recent suicide attempts and
regularly burned herself with cigarettes and a hot
iron. In individual sessions, treatment initially
focused on clarifying her own feelings and others'
experience of her; later it progressed to helping
her appreciate how her experiences of self-doubt and
emotional turbulence led to a sense of fragmentation
that was controlled only by experiences of intense
physical pain, according to Bateman and Fonagy.

“The
individual therapist identified these processes
while focusing on the way she represented her own
mental states and those of others with whom she
interacted,” they wrote. “Gradually this was
explored within the relationship with the
therapist.”

They
report the patient as stating, “It never occurred to
me that what I did had an effect on anyone else.”

As
explained in the 1999 AJP report, the
original study was conducted at the Halliwick
Psychotherapy Unit at St. Ann's Hospital in London.
Halliwick offers partial hospitalization consisting
of long-term psychoanalytically oriented treatment
to 30 patients aged 16 to 65 who have borderline or
severe personality disorder.

Forty-four patients were randomly assigned either to
treatment by means of partial hospitalization or to
standard outpatient psychiatric treatment.

Mentalization-based treatment by partial
hospitalization consisted of 18-month individual and
group psychotherapy in a partial-hospital setting
offered within a structured and integrated program
provided by a supervised team.

Treatment for the partially hospitalized group
consisted of once-weekly individual psychoanalytic
psychotherapy; thrice-weekly group analytic
psychotherapy (one hour each); and a weekly
community meeting (one hour), all spread over five
days. In addition, on a once-per month basis,
subjects had a meeting with the case administrator
(one hour) and medication review by the resident
psychiatrist.